- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,434.66 / $1,434.66 / $1,434.66
| Facility | | $1,434.66 | $1,434.66 | $1,434.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,846.14 / $4,846.14 / $4,846.14
| Professional | | $4,846.14 | $4,846.14 | $4,846.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,378.23 / $1,621.45 / $1,621.45
| Professional | | $1,378.23 | $1,621.45 | $1,621.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $1,505.28 / $4,552.00
| Facility | | $55.00 | $1,505.28 | $4,552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,045.29 / $1,494.43 / $10,107.12
| Professional | | $1,045.29 | $1,494.43 | $10,107.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.04 / $1,449.34 / $2,049.94
| Professional | | $1,013.04 | $1,449.34 | $2,049.94 |